DEFINING PROBLEMS. SHAPING SOLUTIONS . - School of Social Service ...

a d v o c a t e s ’ f o r u m
Chronic disease management requires individuals to be knowledgeable
about the trajectory of their disease so that the patient and family members
are able to identify abnormal symptoms. In this model, affected individuals
are expected to comply with physician-ordered regimens for care, such as
the taking of daily medications (Gellad et al. 2011). The goal of chronic
disease management is to help patients self-identify an irregularity before
the condition progresses to a life-threatening or highly debilitating level.
In order to monitor the disease, chronically ill individuals are expected to
have a regular health care provision team that understands the patient’s
unique medical and social history (Wagner 2000). As a result of having
a provision team, the lead physician is able to work with the patient to
maintain wellness through routine appointments even if the patient is
not experiencing problematic symptoms. Collecting a social history and
educating the patient are essential aspects of chronic disease management
(Wagner 2000). Patients who understand their disorder, monitor their
symptoms, and comply with prescribed regimens through the assistance of
integrated care teams are more likely to receive higher quality care (Ouwens
et al. 2004). Therefore, it is important that the medical team is integrated
with social workers or community health workers who are acutely aware of the
conditions of poverty that may impact a patient’s ability to manage an illness.
Disease management can increase quality of life for the patient, but
hospitals and physicians are also key beneficiaries of a chronic disease
management approach. From the physician’s perspective, it is advantageous
to regularly interact with individuals at risk for developing complex
symptoms. More closely understanding the patient’s condition helps
providers to identify abnormalities before they progress to dangerous,
complex, and ultimately untreatable levels. It is useful for the medical
team to also understand the patient’s social environment as one’s location
in society may impact the ability to follow through with treatment plans.
Finally, hospital systems are also likely to monetarily benefit from disease
management, as “charity cases,” i.e., poor individuals lacking adequate
health insurance coverage, are less likely to require costly hospital
admission. In addition, due to disease management, profitable higher acuity
cases can replace less acute cases (Woods et al. 2011).
While the benefits of chronic disease management are numerous,
the implementation of this model of care provision is currently flawed,
especially with regard to low-income, inner-city patients. Adequate
disease control requires that a patient have a regular health-care provider
who coordinates and co-manages care, thereby preventing the patient’s
hospitalization. Unfortunately, however, poor individuals receiving health
insurance through public aid programs, such as Medicaid or the State
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